Review of Systems- Please circle Yes or no Name: ______DOB: ______

CONSTITUTIONAL URINARY Fever Yes No Hematuria (blood in urine) Yes No Night Sweats Yes No Burning with urination Yes No Weight Gain Yes No MUSCULOSKELETAL Weight Loss Yes No Joint or Yes No Intolerance Yes No SKIN EYES Yellowing of skin Yes No Dry eyes Yes No Rashes Yes No Eye Irritation Yes No NEUROLOGICAL Vision Changes Yes No Fainting or Loss of Consciousness Yes No EARS/NOSE Yes No Difficulty Hearing Yes No Numbness Yes No Ear Pain Yes No Seizures Yes No Nosebleeds Yes No Yes No Sinus Problems Yes No /Migraines Yes No MOUTH/THROAT PSYCHIATRIC Sore throat Yes No Depression/Anxiety Yes No Bleeding Gums Yes No Sleep Problems Yes No Snoring Yes No Feeling safe in relationship Yes No Dry Mouth Yes No Alcohol use ____drinks a day or____ drinks Yes No per week Mouth ulcers Yes No ENDOCRINE Teeth problems Yes No Yes No CARDIOVASCULAR Increased thirst Yes No Chest Pain Yes No Hair Loss Yes No Arm pain with exertion Yes No Increased hair growth Yes No Short of breath when walking Yes No Cold Intolerance Yes No Short of breath when lying down Yes No HEMATOLOGIC Palpitations Yes No Swollen glands Yes No heart Murmur Yes No Easy bruising Yes No Have you seen a cardiologist Yes No Excessive bleeding Yes No RESPIRATORY ALLERGY/IMMUNOLOGIC Cough Yes No Runny nose Yes No Wheeze Yes No PREGNANT NOW Yes No Yes No PLANNING PREGNANCY Yes No Coughing up blood Yes No Frequent Sneezing Yes No GI FAMILY HISTORY Abdominal pain Yes No Colon Cancer Yes No or Yes No Who? Poor appetite Yes No Colon Polyps Yes No Diarrhea Yes No Who? Constipation Yes No Esophageal Cancer Yes No Heartburn/Reflux Yes No Who? Rectal Bleeding Yes No Stomach Cancer Yes No Problems swallowing Yes No Who? Change in Bowel Habits Yes No Other Cancers in Family? Yes No

Primary Care Physician: ______Signature: ______Date: ______